Comparing Public Perceptions and Preventive Behaviors During the Early Phase of the COVID-19 Pandemic in Hong Kong and the United Kingdom: Cross-Sectional Survey Study

JOURNAL OF MEDICAL INTERNET RESEARCH Bowman et al

Original Paper Comparing Public Perceptions and Preventive Behaviors During the Early Phase of the COVID-19 Pandemic in Hong Kong and the United Kingdom: Cross-sectional Survey Study

Leigh Bowman1, PhD; Kin On Kwok2,3,4, PhD; Rozlyn Redd5, PhD; Yuanyuan Yi2, MPH; Helen Ward1,5, PhD; Wan In Wei2, MPhil; Christina Atchison5, PhD; Samuel Yeung-Shan Wong2, MD 1MRC Centre for Global Infectious Disease Analysis and Abdul Latif Jameel Institute for Disease and Emergency Analytics (J-IDEA), School of Public Health, Imperial College, London, United Kingdom 2JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, Hong Kong 3Stanley Ho Centre for Emerging Infectious Diseases, The Chinese University of Hong Kong, Hong Kong, Hong Kong 4Shenzhen Research Institute, The Chinese University of Hong Kong, Hong Kong, Hong Kong 5Patient Experience Research Centre, School of Public Health, Imperial College London, London, United Kingdom

Corresponding Author: Kin On Kwok, PhD JC School of Public Health and Primary Care The Chinese University of Hong Kong Room 419, 4/F, JC School of Public Health and Primary Care Building, Prince of Wales Hospital Shatin, New Territories Hong Kong Hong Kong Phone: 852 22528405 Email: [email protected]

Abstract

Background: Given the public health responses to previous respiratory disease pandemics, and in the absence of treatments and vaccines, the mitigation of the COVID-19 pandemic relies on population engagement in nonpharmaceutical interventions. This engagement is largely driven by risk perception, anxiety levels, and knowledge, as well as by historical exposure to disease outbreaks, government responses, and cultural factors. Objective: The aim of this study is to compare psychobehavioral responses in Hong Kong and the United Kingdom during the early phase of the COVID-19 pandemic. Methods: Comparable cross-sectional surveys were administered to adults in Hong Kong and the United Kingdom during the early phase of the epidemic in each setting. Explanatory variables included demographics, risk perception, knowledge of COVID-19, anxiety level, and preventive behaviors. Responses were weighted according to census data. Logistic regression models, including effect modification to quantify setting differences, were used to assess the association between the explanatory variables and the adoption of social distancing measures. Results: Data from 3431 complete responses (Hong Kong, 1663; United Kingdom, 1768) were analyzed. Perceived severity of symptoms differed by setting, with weighted percentages of 96.8% for Hong Kong (1621/1663) and 19.9% for the United Kingdom (366/1768). A large proportion of respondents were abnormally or borderline anxious (Hong Kong: 1077/1603, 60.0%; United Kingdom: 812/1768, 46.5%) and regarded direct contact with infected individuals as the transmission route of COVID-19 (Hong Kong: 94.0%-98.5%; United Kingdom: 69.2%-93.5%; all percentages weighted), with Hong Kong identifying additional routes. Hong Kong reported high levels of adoption of various social distancing measures (Hong Kong: 32.6%-93.7%; United Kingdom: 17.6%-59.0%) and mask-wearing (Hong Kong: 98.8% (1647/1663); United Kingdom: 3.1% (53/1768)). The impact of perceived severity of symptoms and perceived ease of transmission of COVID-19 on the adoption of social distancing measures varied by setting. In Hong Kong, these factors had no impact, whereas in the United Kingdom, those who perceived their symptom severity as ªhighº were more likely to adopt social distancing (adjusted odds ratios [aORs] 1.58-3.01), and those who perceived transmission as ªeasyº were prone to adopt both general social distancing (aOR 2.00, 95% CI 1.57-2.55) and contact avoidance (aOR 1.80, 95% CI 1.41-2.30). The impact of anxiety on adopting social distancing did not vary by setting.

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Conclusions: Our results suggest that health officials should ascertain baseline levels of risk perception and knowledge in populations, as well as prior sensitization to infectious disease outbreaks, during the development of mitigation strategies. Risk should be communicated through suitable media channelsÐand trust should be maintainedÐwhile early intervention remains the cornerstone of effective outbreak response.

(J Med Internet Res 2021;23(3):e23231) doi: 10.2196/23231

KEYWORDS COVID-19; novel coronavirus; pandemic; behavioural response; risk perceptions; anxiety; comparative; Hong Kong; United Kingdom

To elucidate these relationships, a more thorough comparative Introduction analysis is required. However, studies in different countries In December 2019, a novel coronavirus, SARS-CoV-2, emerged often use different metrics to measure the same behavior, which in Wuhan, Hubei Province, China, and spread rapidly can lead to difficulty when interpreting the significance of worldwide, forming the second pandemic of the 21st century heterogeneous contexts. [1]. The progression of the disease has varied by region. As of In this study, we examined and compared public perception and August 2, 2020, there have been at least 17 million cases of adoption of preventive behaviors in response to the early phase COVID-19 and over 670,000 deaths globally [2]. of the COVID-19 pandemic in two different settings: Hong Prior to the availability of effective treatments and vaccines, Kong and the United Kingdom. We further investigated the strategies to mitigate the impact of the pandemic have been factors associated with greater adoption of different types of primarily nonpharmaceutical [3], mainly focusing on public social distancing measures. Our results have immediate health promotion of using simple but effective preventive implications on how health officials plan and communicate measures [4,5]. Many important control strategies currently strategies to mitigate the ongoing COVID-19 pandemic to promoted by governments require public participation, either communities. through direct adoption of preventative behaviors, such as handwashing or wearing face masks, or through compliance Methods with social distancing policies, such as recommendations to avoid public transport and mass gatherings. Study Design and Recruitment In Hong Kong and the United Kingdom, cross-sectional surveys Previous studies of the severe acute respiratory syndrome and were conducted during the early phase of the COVID-19 influenza pandemics showed that governments should account pandemic, when limited government-level interventions were for risk perception and anxiety when promoting preventative in place [5,18]. The survey period in Hong Kong was from measures. There is evidence that higher perceived risk of January 24 to February 13, 2020, and that in the United infection is associated with increased adoption of precautionary Kingdom was from March 17 to 18, 2020. In Hong Kong, the measures [6,7], while increased anxiety has also been shown to first laboratory-confirmed case of COVID-19 was reported on increase the likelihood that people will engage in protective January 23, 2020, and the number of cases rose to 53 by behaviors [8]. Moreover, longitudinal data suggest that these February 13, 2020 [19]; meanwhile, in the United Kingdom, perceptions, behaviors and anxieties change with context and the first two laboratory-confirmed cases were reported on over time as uncertainty about disease severity decreases and January 31, 2020, and the number of cases rose to 2626 by knowledge of transmission increases [9]. March 18, 2020 [20]. During the current COVID-19 pandemic, researchers have In Hong Kong, all 452 district councilors were invited to examined public risk perceptions and knowledge in various distribute an open web-based survey by sharing a survey link countries, including Finland [10], Israel [11], Italy [12], Nigeria and promotion messages on their webpages, social media [13], the United States [14,15], South Korea [16] and Vietnam platforms, or any channels which they usually used to convey [17]. However, only a few studies have identified the factors information to their targeted residents. Individuals aged ≥18 associated with greater adoption of preventative measures or years who understood Chinese and lived in Hong Kong were how these associations vary by context. In Hong Kong, both eligible to participate [5]. Respondents were compensated with greater understanding of COVID-19 and increased anxiety were HK $10 (US $1.29) in the form of a cash coupon. In the United associated with greater adoption of social distancing behaviors Kingdom, the web-based survey was not open (users were [5], whereas in the United Kingdom, there was a significant required to log in) and was administered by YouGov, a market socioeconomic gradient in the ability to adopt and comply with research company, to members of its panel of ≥800,000 social distancing measures, specifically the ability to work from individuals (aged ≥18 years) as part of their omnibus survey home and the ability to self-isolate [18]. [21]. Our UK sample was obtained through a nonprobabilistic This initial evidence that there is variation across context in active sampling method, and emails were sent to randomly affective responses, risk perceptions, and the impact of selected individuals with particular characteristics to match the sociodemographic factors on the uptake of preventative proportions of people with those characteristics in the 2011 UK behaviors has significant implications when tailoring policies.

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census. No incentive was involved in the UK survey. More regression models were used to identify sociodemographic and details of the survey design are described elsewhere [5,18]. psychosocial factors associated with the adoption of three types of social distancing: (1) general measures, specified by avoiding Study Instruments crowded places, social events and going out; (2) contact The study instruments are freely available on the web (Hong measures, specified by avoiding contact with individuals who Kong: [22]; United Kingdom: [23]). The UK questionnaire was had fever or respiratory symptoms and who had been to affected adapted from the Hong Kong version, with feedback from 20 areas recently; and (3) work measures, specified by avoiding members of the public (of different backgrounds) to improve going to work. its relevance and usability in the UK context. This process led to some discrepancies in the questions or answer choices; Common and comparable sociodemographic factors considered however, the two questionnaires were largely similar. in separate analytical studies [5,18] were included in this comparative analysis. These factors were considered as Sociodemographic variables included age, sex, educational confounders in the association between psychosocial factors attainment, and employment status. Anxiety level was measured (including anxiety level, perceived severity, and perceived ease using the Hospital Anxiety and Depression scale±Anxiety of transmission) and adoption of social distancing measures. (HASD-A) (0-7=normal; 8-10=borderline abnormal; Further, these associations (between each aforementioned 11-21=abnormal) [24]. Risk perception toward COVID-19 was psychological factor and each type of social distancing measure) measured by perceived severity of symptoms if the respondent were considered a priori to be affected by setting. Therefore, was infected with COVID-19 (Hong Kong, question 35; United we examined the effect modifications due to setting using Kingdom, question GIC_Q29). Knowledge of COVID-19 was interaction terms in the baseline models, which can be assessed by asking whether COVID-19 could be transmitted interpreted as the difference in the estimated effects of through various routes (Hong Kong, question 45; United psychosocial factors on adopting social distancing measures Kingdom, question GIC_Q33), including direct human exposure due to different settings. Adjusted odds ratios (aORs) and 95% (eg, physical contact or a face-to-face conversation with confidence intervals were estimated. Associations with P<.05 someone who is infected with SARS-CoV-2 with or without in the adjusted analyses were considered to be statistically symptoms) and other types of exposure (eg, visiting wet markets significant. Analyses were conducted in R, version 3.6.3 (the or consumption of wild animal meat). From knowledge of R Project) and STATA, version 11 (StataCorp LLC). COVID-19, perceived ease of transmission was regarded as ªeasyº if the virus was deemed to be transmitted through face-to Ethical Approval face conversation with asymptomatic infectees and as ªdifficultº The study was approved by the Imperial College London otherwise. Respondents were also asked about the sources from Research Ethics Committee (reference number: 20IC5861) and which they retrieved information about COVID-19 and their the Survey and Behavioral Research Ethics Committee of The perceived reliability of these sources (Hong Kong, questions Chinese University of Hong Kong (reference number: 40 and 43; United Kingdom, questions GIC_Q30 and SBRE-19-625). GIC_Q32). In addition, they were asked about the adoption of preventative behaviors to prevent the transmission of COVID-19 Results (Hong Kong, question 46; United Kingdom, questions GIC_Q34a and GIC_Q34b). Three types of preventative Survey Responses measures were considered: personal hygiene, social distancing, In Hong Kong, there were initially 2478 clicks on the survey and travel avoidance. link. After removing 763 cases with missing demographics and Data Analysis 52 cases with ambiguous responses on the perceived ease of transmission, 1663 complete cases were included in the analysis. Descriptive statistics for all variables present the number of In the United Kingdom, 2500 individuals were approached, and respondents and the raw or weighted percentages. In this the response rate was 84.3% (2108/2500). After excluding cases manuscript, weighted percentages were used for description with missing demographics or perceived severity and cases with except for demographics. The responding samples were ambiguous responses on the perceived ease of transmission, weighted to be representative of the United Kingdom (2011 1768 cases were included in the analysis. census [25]) and Hong Kong (2016 by-census [26]) adult populations using the raking method [27]. Each data point was Demographic Differences given a weight so that the marginal proportions of the There were significant differences in the sociodemographic demographics in the survey (age, sex, region, education level, characteristics of the study respondents between the two settings. and [United Kingdom only] social grade) were similar to those Hong Kong respondents were younger, with 26.0% (433/1663) in the census. Chi-square goodness-of-fit tests were used for aged 18-24 years, compared with 9.4% (166/1768) for the comparing characteristics across settings. Multivariate logistic United Kingdom (P<.001) (Table 1).

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Table 1. Characteristics of the study respondents in the United Kingdom and Hong Kong (all P values <.001 as determined by chi-square goodness-of-fit test). Characteristics United Kingdom (n=1768) Hong Kong (n=1663) n % (unweighted) % (weighted) n % (unweighted) % (weighted) Age (years) 18-24 166 9.4 9.9 433 26.0 17.0 25-34 243 13.7 14.3 535 32.2 23.5 35-44 335 18.9 19.5 370 22.2 23.9 45-54 300 17.0 17.7 193 11.6 22.2 ≥55 724 41.0 38.6 132 7.9 13.4 Sex Female 936 52.9 51.8 1141 68.6 57.1 Male 832 47.1 48.2 522 31.4 42.9 Education attainment No formal qualification/lower sec- 100 5.7 5.5 53 3.2 9.9 ondary or below Secondary level qualification/higher 738 41.7 43.2 292 17.6 32.5 secondary Postsecondary but below degree 334 18.9 18.3 267 16.1 16.2 Degree or above 596 33.7 32.9 1051 63.2 41.5 Employment status Employer/employee 1025 58.0 59.6 1135 68.3 66.0 Full-time student 90 5.1 5.3 278 16.7 12.5 Unemployed/not working 172 9.7 10.4 206 12.4 17.2 Retired 481 27.2 24.7 44 2.6 4.3

Perceived severitya Level 1 96 5.4 5.2 1071 64.4 65.0 Level 2 270 15.3 14.7 550 33.1 31.8 Level 3 1058 59.8 60.2 32 1.9 2.2 Level 4 320 18.1 18.5 7 0.4 0.7 Level 5 24 1.4 1.4 3 0.2 0.3 Worry about COVID-19 Very worried 536 30.3 30.1 852 51.2 49.4 Fairly worried 858 48.5 48.4 723 43.5 43.2 Neutral/don't know 5 0.3 0.3 40 2.4 3.2 Not very worried 295 16.7 16.9 1 0.1 0.1 Not at all worried 74 4.2 4.3 47 2.8 4.1 Anxiety level Normal 956 54.1 53.5 586 35.2 40.0 Borderline abnormal 336 19.0 19.4 512 30.8 27.3 Abnormal 476 26.9 27.1 565 34.0 32.7

aLevel 1=very serious (Hong Kong)/life-threatening (United Kingdom); Level 2=serious (Hong Kong)/severe (eg, may need care and treatment in hospital) (United Kingdom); Level 3=neutral (Hong Kong)/moderate (eg, may need self-care and rest in bed) (United Kingdom); Level 4=not serious (Hong Kong)/mild (eg, can go about daily tasks normally) (United Kingdom); Level 5=not serious at all (Hong Kong)/no symptoms (United Kingdom).

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The Hong Kong sample contained a greater proportion of Knowledge and Information Sources women (Hong Kong: 1141/1663, 68.6%, vs United Kingdom: The majority of respondents regarded direct contact with 936/1768, 52.9%; P<.001), and respondents educated to infected individuals (Hong Kong: 94.0%-98.5%; United university degree level or above (Hong Kong: 1051/1663, Kingdom: 69.2%-93.5%) or virus-contaminated environments 63.2%, vs United Kingdom: 596/1768, 33.7%; P<.001). (Hong Kong: 1594/1663, 96.3%; United Kingdom: 1411/1768, Employment status reflected the age structure of the respondents 79.5%) as the primary means of virus transmission (Table 2). in each setting, with a greater proportion of UK respondents in However, respondents from Hong Kong identified a far broader the retired category (Hong Kong: 44/1663, 2.6%, vs United scope of transmission routes. A much larger proportion of Hong Kingdom: 481/1768, 27.2%; P<.001) (Table 1). Kong respondents regarded wild animal meat (Hong Kong: Perceptions and Beliefs 1546/1663, 93.4%; United Kingdom: 199/1768, 11.3%), wet markets (Hong Kong: 1342/1663, 81.1%; United Kingdom: Higher perceived severity of COVID-19 was observed among 374/1768, 21.5%), imported seafood (Hong Kong: 1199/1663, Hong Kong respondents, with 96.8% (1621/1663) rating the 70.9%; United Kingdom: 258/1768, 14.8%) and imported goods symptoms of COVID-19 infection as serious or very serious (Hong Kong: 1101/1663, 66.6%; United Kingdom: 209/1768, compared with only 19.9% (366/1768) of the UK respondents. 12.1%) as potential exposure sources than their UK counterparts. In terms of levels of concern, 92.6% (1575/1663) of the Hong There was also significant variation across use and reliability Kong sample responded that they felt very or fairly worried, of information sources (Table S1 in Multimedia Appendix 1). compared with 78.5% (1394/1768) of the UK sample. The The majority of respondents deemed health professionals to be HADS-A scores reflected similar trends, with 60.0% reliable (>80% in both Hong Kong and the United Kingdom); (1077/1663) of the Hong Kong sample recording an abnormal however, few could access them (Hong Kong: 86/1663, 4.8%; or borderline abnormal result, compared with 46.5% (812/1768) United Kingdom: 202/1768, 11.5%). In addition, most UK of the UK sample (Table 1). respondents (1602/1768, 90.7%) considered official websites to be reliable, compared to 15.6% (260/1663) among Hong Kong respondents at the beginning of the pandemic.

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Table 2. Knowledge of COVID-19 transmission. ªAre the following transmission routes of COVID-19?º Respondents answering ªyesº United Kingdom (n=1768) Hong Kong (n=1663) n % (unweighted) % (weighted) n % (unweighted) % (weighted) Contact Face-to-face conversation (no physical contact) with 1234 69.8 69.2 1564 94.0 94.0 someone who has SARS-CoV-2 but no symptoms Face-to-face conversation (no physical contact) with 1398 79.1 78.7 1616 97.2 96.8 someone who has SARS-CoV-2 with symptoms Physical contact with someone who has SARS-CoV-2 1580 89.4 89.0 1635 98.3 98.1 but no symptoms Physical contact with someone with SARS-CoV-2 who 1657 93.7 93.5 1644 98.9 98.5 has symptoms Transmission mode

Droplets N/Aa N/A N/A 1649 99.2 99.2 Aerosol when infected people cough or sneeze N/A N/A N/A 1478 88.9 91.2 Being in close contact (ie, within 2 meters) with some- 1604 90.7 90.4 N/A N/A N/A one who has SARS-CoV-2 when they cough or sneeze Being further away (ie, further than 2 meters) from 615 34.8 34.8 N/A N/A N/A someone who has SARS-CoV-2 when they cough or sneeze Others Contact with virus-contaminated environment 1411 79.8 79.5 1594 95.9 96.3 Consumption of wild animal meat 199 11.3 11.3 1546 93.0 93.4 Visiting a wet market 374 21.2 21.5 1342 80.7 81.1

Consumption of seafood imported from specific regionsb 258 14.6 14.8 1199 72.1 70.9 Consumption/use of products imported from specific 209 11.8 12.1 1101 66.2 66.6 regionsb

aN/A: not applicable. bSpecific regions refer to China (United Kingdom)/Wuhan (Hong Kong). (53/1768) among the UK respondents. General measures were Adoption of Social Distancing Measures adopted by 63.1%-87.2% and 37.8%-59.0% of respondents in There were variations in the weighted proportions of Hong Hong Kong and the United Kingdom, respectively. Contact Kong and the UK respondents who adopted precautionary measures were adopted by 83.8%-93.7% and 33.7%-50.1% of measures against COVID-19 (Figure 1; Table S2 in Multimedia respondents in Hong Kong and the United Kingdom, Appendix 1). Hong Kong respondents reported higher levels of respectively. Work measures were reported by 32.6% (402/1135) adoption across all social distancing and personal hygiene and 22.5% (231/1025) of respondents in Hong Kong and the measures. In particular, 98.8% (1647/1663) of Hong Kong United Kingdom, respectively. respondents reported wearing a face mask, compared to 3.1%

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Figure 1. Adoption of precautionary measures against COVID-19. ªAffected areasº refers to China (Hong Kong)/affected areas in the world (United Kingdom); ªSpecific regions in a limited periodº refers to Wuhan in the past one month (Hong Kong)/affected areas in the past 14 days (United Kingdom). The ªGoing to workº category only included respondents who were employees or employers (n=2160), and the ªGoing to school/letting your children go to schoolº category only included respondents who were full-time students or had at least one child (n=1239).

Sociodemographic factors were associated with the three social but more likely to be adopted by the unemployed (aOR 1.65; distancing measures (Table S3 in Multimedia Appendix 1; Table 95% CI 1.30-2.09) or retired (aOR 1.92; 95% CI 1.43-2.59). 3). The UK respondents were significantly less likely than their Contact measures were less likely to be adopted by male Hong Kong counterparts to adopt social distancing measures respondents (aOR 0.74; 95% CI:0.63-0.88) but more likely to (Table S3 in Multimedia Appendix 1, OR 0.08-0.53, P<.001; be adopted by those who were retired (aOR 1.40; 95% CI Table 3, aOR 0.08-0.70, P<.001). When adjusting for differences 1.03-1.91). Finally, work measures were less likely to be adopted between settings, general measures were less likely to be by respondents aged ≥55 years (aOR 0.60; 95% CI 0.39-0.93). adopted by male respondents (aOR 0.82; 95% CI 0.71-0.95)

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Table 3. Factors associated with the adoption of different social distancing measures. Factor Types of social distancing measures

Generala (n=3431) (Model 1) Contactb (n=3431) (Model 2) Workc (n=2160) (Model 3)

aORd (95% CI) P value aOR (95% CI) P value aOR (95% CI) P value Age (years)

18-24 Reference N/Ae Reference N/A Reference N/A 25-34 1.54 (1.16-2.05) .003 0.96 (0.68-1.35) .81 1.00 (0.72-1.39) .99 35-44 1.25 (0.93-1.68) .13 0.74 (0.53-1.05) .09 0.95 (0.68-1.33) .77 45-54 1.30 (0.95-1.79) .10 0.67 (0.47-0.97) .03 0.72 (0.49-1.05) .09 55+ 0.99 (0.70-1.41) .97 0.81 (0.55-1.19) .28 0.60 (0.39-0.93) .02 Sex Female Reference N/A Reference N/A Reference N/A Male 0.82 (0.71-0.95) .01 0.74 (0.63-0.88) <.001 0.95 (0.78-1.16) .62 Education attainment No formal qualification/lower Reference N/A Reference N/A Reference N/A secondary or below Secondary level qualifica- 0.99 (0.68-1.44) .96 0.96 (0.64-1.44) .85 1.04 (0.46-2.34) .92 tion/higher secondary Postsecondary but below de- 1.06 (0.72-1.55) .78 1.12 (0.74-1.71) .58 1.09 (0.48-2.47) .83 gree Degree or above 1.27 (0.87-1.83) .21 0.98 (0.66-1.47) .94 1.94 (0.88-4.28) .10 Employment status Employed Reference N/A Reference N/A N/A N/A Full-time student 1.35 (0.98-1.85) .07 1.08 (0.73-1.59) .70 N/A N/A Unemployed 1.65 (1.30-2.09) <.001 1.20 (0.91-1.58) .20 N/A N/A Retired 1.92 (1.43-2.59) <.001 1.40 (1.03-1.91) .03 N/A N/A Setting Hong Kong Reference N/A Reference N/A Reference N/A United Kingdom 0.35 (0.30-0.41) <.001 0.08 (0.07-0.10) <.001 0.70 (0.57-0.87) <.001

aGeneral: avoiding going to crowded areas; going to social events; and going out. bContact: avoiding contacting individuals who had a fever or respiratory symptoms and had been to Wuhan in the past month (Hong Kong)/affected areas in the past 14 days (United Kingdom). cWork: avoiding going to work. daOR: adjusted odds ratio. eN/A: not applicable. The impact of perceived severity of infection (Table 4) and measures (Model 5.2, aOR 1.80, 95% CI 1.41-2.30). On the perceived ease of transmission (Table 5) on the adoption of other hand, the impact of anxiety on the adoption of social social distancing behaviors varied by setting. In Hong Kong, distancing behaviors did not significantly differ by setting (Table these factors had no impact, whereas in the United Kingdom, 6). Those with borderline abnormal (Hong Kong, aOR those who perceived COVID-19 infection as serious were more 1.26-1.62; United Kingdom, aOR 1.36-1.48) or abnormal (Hong likely to adopt all social distancing measures (aOR 1.58-3.01), Kong, aOR:1.82-2.09; United Kingdom, aOR:1.40-2.40) and those who perceived transmission of SARS-CoV-2 as easy HADS-A scores were more likely to adopt all three types of were more likely to adopt both general social distancing social distancing measures compared to those with normal measures (Model 4.2, aOR 2.00, 95% CI 1.57-2.55) and contact anxiety levels.

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Table 4. Setting-specific effects and effect modification (by setting) of perceived severity on the adoption of social distancing measures. The models have been adjusted for all covariates. Settings and variables Types of social distancing Model 4.1 Model 5.1 Model 6.1

Generala (n=3431) Contactb (n=3431) Workc (n=2160)

aORd (95% CI) P value aOR (95% CI) P value aOR (95% CI) P value Hong Kong

Not seriouse Reference N/Af Reference N/A Reference N/A

Seriousg 0.93 (0.50-1.74) .82 1.71 (0.85-3.47) .13 0.63 (0.30-1.30) .21 United Kingdom Not serious Reference N/A Reference N/A Reference N/A

Serious 3.01 (2.35-3.86) <.001 1.90 (1.48-2.43) <.001 1.58 (1.06-2.37) .03

Effect modificationh 3.24 (1.65-6.35) <.001 1.11 (0.52-2.34) .79 2.52 (1.09-5.80) .03

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Table 5. Setting-specific effects and effect modification (by setting) of perceived ease of transmission on the adoption of social distancing measures. The models have been adjusted for all covariates. Settings and variables Types of social distancing Model 4.2 Model 5.2 Model 6.2

Generala (n=3431) Contactb (n=3431) Workc (n=2160)

aORd (95% CI) P value aOR (95% CI) P value aOR (95% CI) P value Hong Kong

Difficulte Reference N/Af Reference N/A Reference N/A

Easyg 1.15 (0.77-1.74) .50 1.00 (0.58-1.71) .99 0.61 (0.37-1.03) .07 United Kingdom Difficult Reference N/A Reference N/A Reference N/A

Easy 2.00 (1.57-2.55) <.001 1.80 (1.41-2.30) <.001 1.34 (0.96-1.87) .09

Effect modificationh 1.73 (1.07-2.79) .02 1.81 (1.00-3.28) .05 2.18 (1.18- 4.04) .01

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Table 6. Setting-specific effects and effect modification (by setting) of anxiety level on the adoption of social distancing measures. The models have been adjusted for all covariates. Settings and variables Types of social distancing Model 4.3 Model 5.3 Model 6.3

Generala (n=3431) Contactb (n=3431) Workc (n=2160)

aORd (95% CI) P value aOR (95% CI) P value aOR (95% CI) P value Hong Kong

Normal Reference N/Ae Reference N/A Reference N/A

Borderline abnormal 1.62 (1.27-2.06) <.001 1.26 (0.93-1.70) .14 1.51 (1.10-2.06) .01 Abnormal 2.09 (1.64-2.66) <.001 1.85 (1.34-2.56) <.001 1.82 (1.34-2.48) <.001 United Kingdom Normal Reference N/A Reference N/A Reference N/A

Borderline abnormal 1.48 (1.11-1.96) .01 1.36 (1.02-1.80) .03 1.37 (0.92-2.02) .12 Abnormal 2.40 (1.87-3.09) <.001 1.76 (1.37-2.27) <.001 1.40 (0.99-1.98) .06

Effect modificationf (borderline abnor- 0.91 (0.63-1.33) .64 1.08 (0.71, 1.63) .71 0.91 (0.55-1.49) .70 mal) Effect modification (abnormal) 1.15 (0.82-1.62) .42 0.95 (0.63-1.42) .80 0.77 (0.48-1.21) .26

aGeneral: avoiding going to crowded areas and social events and going out. bContact: avoiding contacting individuals who had a fever or respiratory symptoms and had been to Wuhan in the past one month (Hong Kong) or affected areas in the past 14 days (United Kingdom). cWork: avoiding going to work. daOR: adjusted odds ratio. eN/A: not applicable. fMeasures the difference of the effect being considered due to difference in setting; its value is the ratio of the two setting-specific effects. and knowledge when designing and promoting mitigation Discussion strategies. The evidence presented in this study demonstrates Principal Results that geographical and sociocultural context is important in terms of both how people understand risk and how risk drives This study compared the initial public perceptions and behavior. Although the social, historical, and cultural preventative behaviors during the COVID-19 pandemic across heterogeneity between Hong Kong and the United Kingdom Hong Kong and the United Kingdom. The adoption of likely contributes to the results of this study, the importance of social-distancing measures was higher in Hong Kong than in intrinsic factors such as population sensitization via past the United Kingdom. Risk perception and knowledge of infectious disease outbreaks and state-led health promotion COVID-19 were consistently and significantly higher in Hong campaigns should not be underestimated. In other studies, public Kong; however, for the United Kingdom, respondents'adoption perceptions of these factors have been found to be significant of preventive behaviors was associated with two metrics: if drivers of adopting preventative behaviors during previous transmission was considered to be ªeasyº and the perceived epidemics [29], while conceptions of personal risk have been severity was ªsevere,º UK respondents were more likely to connected to individuals' understanding of local disease adopt preventive behaviors. Anxiety was a driver of behavior prevalence and severity [30-32]. Therefore, assessment of the change in both settings: those who were more anxious were baseline population knowledge, attitudes, and practices (KAP) more likely to adopt preventative measures. This behavior is and subsequent continual monitoring throughout the pandemic consistent with the wider literature surrounding the adoption of are essential to effective context-specific pandemic preparedness precautionary measures [6,7] and provides further evidence that plans. anxiety drives protective behaviors, such as handwashing [8], an effective intervention against the transmission of respiratory Second, risk communication should build upon baseline KAP diseases [28]. outcomes, and trust should be developed across suitable media channels. Significant contextual heterogeneity in the public Implications reliance on information sources provides insight here. Hong This study has three implications. First, health officials should Kong reported greater reliance on social media and far less trust account for context-specific baseline levels of risk perception in official websites, suggesting that official messaging in Hong

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Kong did not likely drive individual behavior change; by a short time frame (2 days). However, this approach likely came contrast, the UK results suggested that although the UK at the expense of excluding participants without access to the government possessed an effective platform to influence public internet, and it contrasted with the survey period in Hong Kong health behavior, government health messaging was insufficient (3 weeks); this likely led to some sampling bias, especially to attain similar baseline knowledge levels to those in Hong during the initial phase of the pandemic (when there was much Kong, particularly in the absence of prior population uncertainty about the disease). Additionally, both samples varied sensitization to infectious disease outbreaks. Therefore, there across the demographic spectrum; thus, although responses is a pressing need to tailor communication approaches, likely were weighted, caution should be taken when extrapolating on a graduated scale, but at a minimum in a binary fashion to study findings to wider populations. Moreover, given the accommodate both ªnaiveº and ªexperiencedº populations. incompatibility of region-specific weights and the controversy in estimating standard errors when survey weights are involved Third, the comparative snapshots of initial community responses [34], unweighted regression results were presented; however, captured by this study demonstrate the diversity in approaches they should be interpreted with caution. Last but not least, and pandemic responses during the early phases of the although both surveys were conducted early locally, the COVID-19 pandemic. Across many contexts, national difference in surrounding international events during the survey lockdowns became commonplace as the true magnitude of periods (eg, the Hong Kong survey was conducted before transmission became apparent; however, the associated indirect COVID-19 was formally declared a pandemic, but the UK costs render blanket strategies untenable in the medium term. survey was launched after this declaration) may have introduced As national lockdowns are lifted, countries worldwide face the bias in the survey responses. challenge of resurging cases and must consider nuanced approaches to prevent additional harm. Driven by anxiety, high Conclusions perceived severity and knowledge, Hong Kong conducted This study compared the initial community responses to widespread preventive measures early and en masse. Together COVID-19 in Hong Kong and the United Kingdom. In line with with early government actions [33], the strategies adopted by the high baseline level of risk perception and knowledge and the Hong Kong community were successful during the initial with historical exposure to respiratory disease outbreaks, the phase of the pandemic. Considering thisÐand that national adoption of preventive measures was higher in Hong Kong. populations are now highly sensitized to COVID-19 However, the UK sample demonstrated that this adoption could transmissionÐtailored public health messaging, early regional be improved by heightened risk perception and knowledge, best containment, and increased health capacity should ensure more driven by improved public health campaigns. Together, these effective public health responses with less indirect impact on results suggest that health officials should ascertain baseline national economies. levels of risk perception and knowledge, as well as prior Study Strengths and Limitations sensitization to infectious disease outbreaks, when developing mitigation strategies. Risk communication should be performed From a methodological perspective, the UK sampling approach through suitable media channelsÐand trust should be enabled the sample size to be achieved quickly, thereby maintainedÐwhile early intervention remains the cornerstone accurately capturing prevailing sentiment and behavior across of effective outbreak response.

Acknowledgments The study was supported by Imperial NIHR Research Capability Funding and the internal funding of The Chinese University of Hong Kong. HW is a National Institute for Health Research (NIHR) Senior Investigator and receives funding from the Imperial NIHR Biomedical Research Centre, the NIHR Applied Research Collaborative North West London, the NIHR School for Public Health Research, and the Wellcome Trust. KOK would like to acknowledge the Research Fund for the Control of Infectious Diseases, Hong Kong (number:INF-CUHK-1); General Research Fund (number:14112818); Early Career Scheme (number: 24104920); Health and Medical Research Fund (numbers:17160302, 18170312); The Wellcome Trust (number: 200861/Z/16/Z); and a Direct Grant for Research of The Chinese University of Hong Kong (CUHK) (number: 2019.020).

Authors© Contributions LRB, KOK, HW, CA, and SYSW conceived the study; KOK, WIW, and CA collected the data; KOK, YYY, and WIW analyzed the data; LRB, KOK, RER, HW, WIW, CA, and SYSW interpreted the data; LRB wrote the first draft of the manuscript; and KOK, RER, YYY, HW, WIW, CA, and SYSW edited the manuscript. LRB and KOK contributed equally as the joint first author. CA and SYSW also contributed equally as the joint last author. KOK and CA also contributed equally as the joint corresponding author.

Conflicts of Interest None declared.

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Multimedia Appendix 1 Supplementary files. [DOCX File , 45 KB-Multimedia Appendix 1]

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Abbreviations aOR: adjusted odds ratio HASD-A: Hospital Anxiety and Depression scale±Anxiety KAP: knowledge, attitudes, and practices

Edited by G Fagherazzi; submitted 05.08.20; peer-reviewed by W Camelo Castillo, B Prainsack; comments to author 19.09.20; revised version received 19.10.20; accepted 01.02.21; published 08.03.21 Please cite as: Bowman L, Kwok KO, Redd R, Yi Y, Ward H, Wei WI, Atchison C, Wong SYS Comparing Public Perceptions and Preventive Behaviors During the Early Phase of the COVID-19 Pandemic in Hong Kong and the United Kingdom: Cross-sectional Survey Study J Med Internet Res 2021;23(3):e23231 URL: https://www.jmir.org/2021/3/e23231 doi: 10.2196/23231 PMID: 33539309

©Leigh Bowman, Kin On Kwok, Rozlyn Redd, Yuanyuan Yi, Helen Ward, Wan In Wei, Christina Atchison, Samuel Yeung-Shan Wong. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 08.03.2021. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the

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Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.

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